Well this is it, the last issue of Health Edition and the 824th since the first one was published on June 6, 1997. It has been a wonderful experience.

That first newsletter came out within a few days of the federal election when Prime Minister Jean Chrétien promised to put an end to any further cuts to health transfers.

A massive infusion of federal funds into health care later began. A Royal Commission and three accords later, here we are at the end of 2013 with the last of the accords soon to expire, and the flow of money — both federal and provincial — again on the ebb as concerns are expressed about the sustainability of current spending patterns.

Yes, it has been an interesting journey and I would like to think that Health Edition has been of some use in helping people stay on top of the myriad developments that have occurred. It has certainly been my pleasure bringing you the news week-in, week-out for 17 years.

I would like to thank those readers who have been with us all this time, as well as the many people who joined us along the way. I would also like to thank Merck for its support of the newsletter since 1998 and its willingness to let us do our own thing.

On a personal note, I would like to thank my wife Debi. Not only has she taken care of administrative matters of the business, and been my stalwart proof-reader, but her unwavering patience and love has carried me through these many years.

With Merck’s support, the www.healthedition.com website will be operational until January 31, 2014. We are currently looking for another home for our archives so that the content can be of continued value to health-care researchers. There is even a chance that Health Edition could continue “under new management” if the appropriate arrangement can be found. If you or your organization is interested in any of these developments, please contact me at jpye@healthedition.com.

Health care spending in Canada, by the public and private sectors, could reach $211 billion in 2013, the Canadian Institute for Health Information informed us at the end of October. After adjusting for inflation and population growth, spending actually decreased by 0.2 per cent – continuing a recent trend of vigorous cost restraint which has occurred globally.

In a paper published by the Macdonald-Laurier Institute in February, Janice MacKinnon, a former finance minister in Saskatchewan, said governments have been limited in their ability to contain health-care costs and continued reliance on general tax revenues is not sustainable.

She argued for the implementation of user fees, and while this has never been a popular notion there have been other calls for consumers to assume some of the costs of their care.

For example, in his January report for the Ontario government on a seniors’ strategy, Dr. Samir Sinha suggested the government explore an income-based approach for home care and community support services. During hearings this fall on Quebec’s proposed assurance autonomie policy for funding continuing care, the suggestion was made that baby boomers shoulder the bulk of the short-term costs since they will be the primary beneficiaries of this service.

Quebec has also decided it cannot afford to abandon health premiums and has linked them to income. And at the annual conference of the Alberta Progressive Conservative party in November there was a resolution to reinstate health premiums abolished in 2009 — an idea which the health minister quickly shot down in the legislature.

Canadians already shell out a lot of money for health care – almost $30 billion out of their own pockets in 2011 – although CIHI calculated in a May study that only the most affluent Canadians contribute significantly more to health care in taxes than they receive in services.

Understandably, Canadians have a strong and abiding affection for their health-care system, and they believe it is in better shape than it was five years ago according to an Ipsos-Reid survey for the Canadian Foundation for Healthcare Improvement, published in February. But, predictably, it found that concerns about timely access to care undermine positive perceptions of the “patient experience.”

Wait times have been a perennial issue for Canadians – an issue tackled by First Ministers in the 10-year health accord in 2004, and bankrolled by billions of dollars in targeted funding.

However, a March report by CIHI found that although a record number of priority surgical procedures and specialized treatments are being performed, wait times have not improved in recent years. This conclusion was backed up in the eighth annual report of the Wait Time Alliance, a consortium of 14 medical groups, in June. It said the wait-time reduction effort had “stalled.”

This is an unfortunate verdict for the lynchpin initiative of the 2004 accord which expires at the end of next March. There is no indication that Ottawa has any interest in renewing the accord, or changing its mind about a new formula for Canada Health Transfers that ties yearly increases to GDP growth.

This is despite repeated warnings from the Parliamentary Budget Officer, the latest coming in September, that it will drive the provinces and territories deeper into debt.

Stakeholders continue to press the federal government to get involved in health reform efforts. This includes setting up a seniors’ care commission, a proposal made by the Canadian Nurses Association in November, to deal with issues surrounding an aging population.

The arrival of Rona Ambrose as health minister in July seemed to signal a more hands-on approach by the federal government.

“Canadians expect us to work together towards solutions in challenging areas – I am certain that we will do just that,” she told the annual meeting of the Canadian Medical Association in August.

She added that encouraging the use of best practices is a policy challenge “worthy of federal leadership” and she told the House of Commons in early December that she is working with the provinces and territories to develop “a health innovation framework that would hopefully bring down some of our costs within the health system.”

While this is encouraging, in April the government pulled the plug on continued funding for the Health Council of Canada which a month later produced a report saying the pace of health reform is too slow.

It followed this up with an even more critical report in September which inferred that a decade of health reform in Canada had largely been a failure. “Canadians didn’t get what they were promised,” Dr. Jack Kitts, chairman of the Council, said in an opinion piece published in the Ottawa Citizen.

Nonetheless, provincial-territorial premiers remain committed to their Health Care Innovation Working Group and at the end of July they declared that home care for seniors, lower prices for brand-name drugs and the appropriate use of diagnostics (particularly MRI and CT scans) will be the group’s new priorities.

Quebec Health Minister Réjean Hébert briefed his provincial-territorial colleagues on assurance autonomie at their October meeting. Its intent is to pool all funding for long-term care and home care and put more emphasis on ways to allow seniors and other vulnerable people to live in their homes. Quebec is warning that unless it does something about growing long-term care costs from an aging population it will bankrupt the health-care system.

The target date for implementing the new approach, albeit with questions still being asked about the financial details, is 2015. Newfoundland and Labrador unveiled its long-awaited Paid Family Caregiving Option in December to be introduced on a pilot basis next March.

As for drugs, First Ministers reduced prices for the top six generics in January, and both Prince Edward Island and New Brunswick have become the last two provinces to introduce catastrophic drug coverage.

Appropriateness of care is an initiative which physicians are being asked to embrace. Earlier this year, New Brunswick Health Minister Ted Flemming threatened a cap on medical expenditures after claiming doctors had not agreed to come up with $20 million in savings in the physician budget. He later said the cap was unnecessary because spending was projected to come in under budget anyway.

At its annual meeting the Canadian Medical Association decided to form a collaborative working group to identify specialty-specific tests and procedures that are inappropriate. However, some delegates expressed concern that governments are using the excuse of providing appropriate care to delist procedures for cost reasons.

Clearly, controlling costs is part of the mantra in health care these days and the bell is around the necks of health regions to make it happen. How serious governments are about this was demonstrated in early November by the British Columbia government when it ordered a sweeping operational review of its largest region, Fraser Health, because it was headed for a third straight budget deficit.

The Nova Scotia Liberals won the October 8 provincial election on a platform that included the amalgamation of health districts, vowing to reinvest savings from “bloated” bureaucracies in front-line care.

Meanwhile, in Alberta, the government has stripped Alberta Health Services of its autonomy. The board of directors was fired in June after it refused Health Minister Fred Horne’s directive to look at overturning scheduled pay-at-risk for executives.

It was one of several incidents which moved the government to get more involved in day-to-day operations. Controversy surrounding the amalgamation of home-care contracts in Edmonton and Calgary was another.

All regions are engaged in making efficiency improvements within their respective territories, and a March report from the Conference Board of Canada — using five case studies from Canada and the U.S. — concluded that process improvements can provide more effective health care and reduce costs.

Dealing with alternate level of care patients — those who are taking up a hospital bed while waiting for a continuing care placement — has been an ongoing focus for process improvement efforts, and the Montreal health region even threatened to fine health facilities $1,000 a day for every patient who is not placed within a certain time frame.

There are other, perhaps less drastic, financial measures in play too. In July, new British Columbia Health Minister Terry Lake (one of the three new provincial health ministers appointed in 2013, the others being Leo Glavine in Nova Scotia and Erin Selby in Manitoba) announced that the government is planning to increase the amount of money health authorities get in patient-focused funding as a way to achieve greater efficiencies in the health system.

At the end of February, the head of the Ontario Hospital Association said the first year of using patient-based funding in the province had gone well although there are challenges ahead as more procedures are added and the costs become more complicated to determine.

Changing the model of care is another initiative – making use of the maximum scope of practice of health professionals. There has been some resistance to the expanded use of licensed practical nurses in the health system, and, in fact, LPNs have driven the growth in nursing supply according to an October CIHI report.

Prince Edward Island has been one of the provinces that has moved in this direction, and Health PEI also had its hands full this year with the downsizing of some rural hospitals.

It opened the Island’s first Collaborative Emergency Centre in October, using paramedics and nurses at one of the affected hospitals to provide overnight emergency are. The model was adopted from Nova Scotia, and Saskatchewan has done the same thing.

Emergency care at rural hospitals was an almost daily subject during the extraordinary summer sitting of the Manitoba legislature with the Opposition saying there are 20 small ERs closed across the province.

Saskatchewan doubled its spending on a rural doctor locum pool in April to help with a similar problem of small hospital emergency services, but Regina had an entirely different problem later in the year when one of the city’s two hospital ERs was on the brink of being closed due to a chronic shortage of resuscitation-capable physicians.

Thankfully, the problem was averted by a last-minute deal with emergency physicians to fill in vacant shifts, but the shortage of these specialists is apparently national, and even international, in scope.

The supply of physicians generally in Canada has improved quite a bit in recent years, as CIHI reported in September, but a couple of weeks later the Royal College of Physicians and Surgeons published a study showing that an alarming proportion of newly-certified specialists are having trouble getting a job in their field.

The National Physician Survey, released in late October, also found unemployment and under-employment of physicians to be an issue, but fully a third of doctors who responded to the survey said they were overworked and two thirds have seen increased demand in recent years for the medical services they provide.

The survey also found high levels of dissatisfaction with access to a number of services, including electronic health records although a record 62 per cent reported using them.

A Harris-Decima survey for Canada Health Infoway in October found virtual unanimity among Canadians that the health system should make full use of digital health tools. Another survey, sponsored by Accenture, found 50 per cent of Canadians would switch doctors to gain online access to electronic medical records.

Canada Health Infoway has already allocated the over $2 billion it has received from the federal government since 2001 to promote e-health. What happens beyond the next federal budget, as well as whether Ottawa will respond to the expiry of the 2004 health accord, remain unanswered questions about its involvement in Canadian health care.

These were just some of the stories we were privileged to cover in 2013. HE

Ontario is crying foul over a change in the Canada Health Transfer (CHT) formula effective 2014-15 which allocates the money on a strict per capita basis. Ottawa is keeping to its commitment to increase transfers by six per cent overall, to $32.1 billion, but population growth creates winners and losers among the provinces. Ontario Health Minister Deb Matthews says her province will only get a 3.4 per cent increase while Alberta will rake in 38 per cent extra. Although, Ontario will receive over $12.3 billion in CHT payments in 2014-15, an increase of $410 million from this year, this is still $300 million less than if had been getting the full six per cent. “This is devastating news for us,” Ms. Matthews told the Toronto Star. “It’s less money to reduce wait times, it’s less money to hire nurses.” As of 2017-18, increases in the CHT will be tied to economic growth, and the November 2013 Economic Update projects them to increase by only 4.4 per cent that year, dropping to 4.2 per cent in 2018-19. (Toronto Star, Dec. 18; Canadian Press, Dec. 17)

Ontario is pushing ahead with establishing non-profit community-based specialty clinics across the province, part of its Action Plan for Health Care released in February 2012. These specialty clinics will provide publicly-insured services, starting with cataract and colonoscopy procedures. Other procedures will be considered for this new model of care, including dialysis, out-patient orthopedic and other specialized services that do not require overnight stays in a hospital. More information at http://news.ontario.ca/mohltc/en/2013/12/improving-access-to-routine-health-procedures.html.

Quebec is looking at cost savings of at least $100 million over three years from joint purchasing efforts. Health Minister Réjean Hébert wants to expand a buying collaborative involving nine health regions which achieved savings of 44 per cent, or $16 million a year, from a pilot project involving electrophysiology, hemodynamics and angiography. (News release)

Saskatchewan is moving closer to having a new provincial health-care linen system. 3sHealth, the province’s shared services organization, has completed negotiations with K-Bro Linen Systems for a 10-year contract to provide the service. It will include a new state-of-the-art plant in Regina that will be owned and operated by the company. An estimated 350 workers in publicly-operated laundries will lose their jobs, but 3sHealth estimates that the province to save almost $98 million over the 10-year contract. (Saskatoon Star-Phoenix, Dec. 14; News release at www.3shealth.ca/newsreleases/plans-finalized-for-the-new-provincial-health-care-linen-system)

There were 227,597 adverse events reported in Quebec health facilities between April and September of this year, the health ministry says. Falls accounted for 33.6 per cent of the total and another 32.1 per cent related to medication errors. Over half the accidents involved seniors 75 years of age and over. There were 126 deaths associated with all the adverse events. (La Presse, Dec. 18; News release)

Canadians are spending less on prescription drugs for the first time since World War II, according to the latest edition of the Canadian Rx Atlas published by the UBC Centre for Health Services and Policy. There has been a decrease of about one per cent due mostly to the genericization of brand-name drugs coming off patent. However, the researchers say costs are set to rise again with new specialized drugs coming on the market. News release and link to the report at www.chspr.ubc.ca/news/news-release-canadian-rx-atlas-maps-billions-savings-%E2%80%93-now.

New Brunswick’s health system has received a “C” grade for 2013, the fourth such grade in a row from the NB Health Council. The composite grade is made up of 137 indicators in six categories: Accessibility (C), Appropriateness (C), Effectiveness (D), Efficiency (D), Safety (A) and Equity (A). The Council attributes a drop in the effectiveness grade from a C to a D in 2013 to a “possible lack of comprehensive management of chronic health conditions” and a same drop in the efficiency grade “to signs of poorer financial performance as depicted by one of the highest average cost per hospital case.” The report is at www.nbhc.ca/sites/default/files/pdf/care_exp_2013/Report%20Card%202013_FINAL.pdf.

Alberta Health Services is being accused of watering down its performance targets. Liberal Leader Raj Sherman says a copy of the targets was briefly posted on the AHS website last week before being removed when he asked the health minister’s office for more details on the measures. He says there are 15 performance indicators and while some have remained the same, the one for emergency department wait times is for 90 per cent of patients to be discharged within seven hours by 2015-16. The old target was 80 per cent within four hours. The health ministry says the new performance targets are still in the draft stage and have not yet been approved. (Edmonton Journal, Dec. 18)